Claves diagnósticas y terapéuticas para el manejo de la hemorragia digestiva alta no varicosa

La hemorragia digestiva alta tiene su origen en una lesión situada entre el esfínter esofágico superior y el ángulo de Treitz. Las causas más frecuentes son la úlcera péptica y la hipertensión portal. El diagnóstico de este síndrome se basa en la anamnesis, exploración física, los datos de laboratorio y la endoscopia oral. Se discute cada uno de ellos, resaltando la importancia de la endoscopia. El tratamiento inmediato en urgencias incluye algunas medidas generales del paciente en shock y medidas hemostáticas especiales. Una vez estabilizado el enfermo hay que administrar el tratamiento farmacológico específico en la hemorragia no varicosa.  PALABRAS CLAVE: Diagnóstico. Tratamiento. Hemorragia digestiva alta

Bleeding risk in endoscopic retrograde cholangiopancreatography: impact of the use of antithrombotic drugs

Aims: To analyze the risk factors for hemorrhage during endoscopic retrograde cholangiopancreatography and the impact of antithrombotic drugs. Material and methods: Data sources: papers indexed in PubMed have been reviewed, as well as those found during the analysis of the bibliography of meta-analysis and reviews. Selection criteria: the references have been firstly evaluated by review of the abstract. After selecting the most significant articles (mainly randomized trials and well-designed case series) these have been deeply analyzed. Evaluation of the studies and synthesis: criteria by the Oxford Centre for Evidence-Based Medicine have been used for the analysis of the references and elaboration of evidence levels. Results: Seven hundred and sixty-five references were found, 753 in PubMed and the Cochrane Library. Twelve studies were selected during the analysis of other published articles (systematic reviews, meta-analysis and clinical practice guidelines). After analyzing the title or the abstract, 655 studies were excluded. Finally, 83 high quality trials or descriptive studies have been included in the analysis. Conclusions: Seven conclusions regarding the risk factors for bleeding and the impact of antithrombotic drugs have been defined

Management of refractory esophageal stenosis in the pediatric age

Introduction: Refractory esophageal stenosis (RES) is a major health problem in the pediatric population. Several techniques such as stent placement or C-mitomycin (CM) have been described as alternative treatments. We present our experience with both techniques, in our case with biodegradable stents (BS) and sometimes the association with stents and CM. Material and methods: Six patients have been included: 2 post-operative fistulas in patients with type I esophageal atresia; 1 operated atresia without fistula; and 3 caustic strictures. 5 BS were placed in 4 children: 3 of them in cases of atresia (2 prosthesis in one case) and the other one in a case of stricture. CM was used in 5 cases: in 2 of them from the beginning, and in the other 3 cases after failure of the stent. Results: When placed in fistulas, BS were fully covered. One of them successfully treated the fistula, but the other one was not effective. One stenosis was successfully treated with SB (in the case of persistent fistula), but recurrence was observed in the other 2 cases. One of these was solved with CM, and the other one needed a second stent. In the remaining 2 cases (one atresia and one caustic stricture) CM was effective after 1 and 2 sessions respectively. Overall, 5 out of 6 stenosis have been successfully treated (83.3%), and 1 out of 2 fistulas (50%). Conclusions: Association of BS and CM has been effective in the management of RES in children

Management of antithrombotic drugs in association with endoscopic procedures

The use of antithrombotic drugs (anticoagulants and antiplatelets) has increased significantly with our understanding of cardiovascular risk. Encountering patients on these therapies who require an endoscopic procedure is therefore increasingly common. At decision making the endoscopist must rely on other specialists (basically cardiologists and hematologists) as risk not only lies among increased bleeding odds but also in the possibility of thrombosis following dose discontinuation or change. Understanding the pharmacology, indications, and risks of endoscopic procedures is therefore essential if sound decisions are to be made. The efforts of four scientific societies have been brought together to provide clinical answers on the use of antiplatelets and anticoagulants, as well as action algorithms and a practical protocol proposal for endoscopy units

Diagnostic and therapeutic features of small bowel involvement in portal hypertension

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity

Usefulness of percutaneous elastography by acoustic radiation force impulse for the non-invasive diagnosis of chronic pancreatitis

Objective: To determine the accuracy of the acoustic radiation force impulse (ARFI) technique for the diagnosis of chronic pancreatitis. Materials and methods: We present an observational, single-center study that included patients with suspected chronic pancreatitis in the period between October 2012 and September 2015 who underwent endoscopic ultrasound (EUS) and were classified according to the standard and Rosemont criteria. The same group of patients was assessed by the ARFI technology using ACUSON S2000™ equipment with Virtual Touch™ Quantification software for the assessment of pancreatic stiffness by obtaining the shear wave velocity (SWV) in the head, body and tail of the pancreas. Data were analyzed using ANOVA and nonparametric correlation methods. Diagnostic accuracy was obtained by analyzing receiver operating characteristic (ROC) curve. Results: A total of thirty-three patients were studied (45.5% women); mean age was 58.3 ± 11.8 years. Seventeen with a diagnosis of chronic pancreatitis and sixteen classified as normal according to standard criteria. A significant difference was detected between the means of SWV in pancreatic body of patients without (SWV: 1.27 m/s) and with chronic pancreatitis (SWV 1.57 m/s), p = 0.037. The area under the ROC curve was 71.3% (95% CI 0.532-0.895) and the accuracy of ARFI for diagnosing chronic pancreatitis was 69.7% for a SWV of 1.4 m/s in the pancreatic body. The SWV means in head (r = 0.421, p < 0.05) and body (r = 0.455, p < 0.05) of the pancreas showed a significant correlation with the number of EUS criteria for chronic pancreatitis. Conclusion: Quantification of pancreatic stiffness with ARFI elastography technique has proven to be useful for the non-invasive diagnosis of chronic pancreatitis

Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators

The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification